Hospital computing and the costs and quality of care: a national study

Cashing in: cost-benefit analysis framework for digital hospitals

BACKGROUND

For many countries, especially those outside the USA without incentive payments, implementing and maintaining electronic medical records (EMR) is expensive and can be controversial given the large amounts of investment. Evaluating the value of EMR implementation is necessary to understand whether or not, such investment, especially when it comes from the public source, is an efficient allocation of healthcare resources. Nonetheless, most countries have struggled to measure the return on EMR investment due to the lack of appropriate evaluation frameworks.

METHODS

This paper outlines the development of an evidence-based digital health cost-benefit analysis (eHealth-CBA) framework to calculate the total economic value of the EMR implementation over time. A net positive benefit indicates such investment represents improved efficiency, and a net negative is considered a wasteful use of public resources.

RESULTS

We developed a three-stage process that takes into account the complexity of the healthcare system and its stakeholders, the investment appraisal and evaluation practice, and the existing knowledge of EMR implementation. The three stages include (1) literature review, (2) stakeholder consultation, and (3) CBA framework development. The framework maps the impacts of the EMR to the quadruple aim of healthcare and clearly creates a method for value assessment.

CONCLUSIONS

The proposed framework is the first step toward developing a comprehensive evaluation framework for EMRs to inform health decision-makers about the economic value of digital investments rather than just the financial value.

COVision: convolutional neural network for the differentiation of COVID-19 from common pulmonary conditions using CT scans

With the growing amount of COVID-19 cases, especially in developing countries with limited medical resources, it is essential to accurately and efficiently diagnose COVID-19. Due to characteristic ground-glass opacities (GGOs) and other types of lesions being present in both COVID-19 and other acute lung diseases, misdiagnosis occurs often - 26.6% of the time in manual interpretations of CT scans. Current deep-learning models can identify COVID-19 but cannot distinguish it from other common lung diseases like bacterial pneumonia. Concretely, COVision is a deep-learning model that can differentiate COVID-19 from other common lung diseases, with high specificity using CT scans and other clinical factors. COVision was designed to minimize overfitting and complexity by decreasing the number of hidden layers and trainable parameters while still achieving superior performance. Our model consists of two parts: the CNN which analyzes CT scans and the CFNN (clinical factors neural network) which analyzes clinical factors such as age, gender, etc. Using federated averaging, we ensembled our CNN with the CFNN to create a comprehensive diagnostic tool. After training, our CNN achieved an accuracy of 95.8% and our CFNN achieved an accuracy of 88.75% on a validation set. We found a statistical significance that COVision performs better than three independent radiologists with at least 10 years of experience, especially in differentiating COVID-19 from pneumonia. We analyzed our CNN's activation maps through Grad-CAMs and found that lesions in COVID-19 presented peripherally, closer to the pleura, whereas pneumonia lesions presented centrally.

Why is biomedical informatics hard? A fundamental framework

Building on previous work to define the scientific discipline of biomedical informatics, we present a framework that categorizes fundamental challenges into groups based on data, information, and knowledge, along with the transitions between these levels. We define each level and argue that the framework provides a basis for separating informatics problems from non-informatics problems, identifying fundamental challenges in biomedical informatics, and provides guidance regarding the search for general, reusable solutions to informatics problems. We distinguish between processing data (symbols) and processing meaning. Computational systems, that are the basis for modern information technology (IT), process data. In contrast, many important challenges in biomedicine, such as providing clinical decision support, require processing meaning, not data. Biomedical informatics is hard because of the fundamental mismatch between many biomedical problems and the capabilities of current technology.

The Impact of Meaningful Use and Electronic Health Records on Hospital Patient Safety

The HITECH Act aimed to leverage Electronic Health Records (EHRs) to improve efficiency, quality, and patient safety. Patient safety and EHR use have been understudied, making it difficult to determine if EHRs improve patient safety. The objective of this study was to determine the impact of EHRs and attesting to Meaningful Use (MU) on Patient Safety Indicators (PSIs). A multivariate regression analysis was performed using a generalized linear model method to examine the impact of EHR use on PSIs. Fully implemented EHRs not attesting to MU had a positive impact on three PSIs, and hospitals that attested to MU had a positive impact on two. Attesting to MU or having a fully implemented EHR were not drivers of PSI-90 composite score, suggesting that hospitals may not see significant differences in patient safety with the use of EHR systems as hospitals move towards pay-for-performance models. Policy and practice may want to focus on defining metrics and PSIs that are highly preventable to avoid penalizing hospitals through reimbursement, and work toward adopting advanced analytics to better leverage EHR data. These findings will assist hospital leaders to find strategies to better leverage EHRs, rather than relying on achieving benchmarks of MU objectives.

Higher Electronic Health Record Functionality Is Associated with Lower Operating Costs in Urban—but Not Rural—Hospitals

Objectives  The aim of the study is to examine the relationship between electronic health record (EHR) use/functionality and hospital operating costs (divided into five subcategories), and to compare the results across rural and urban facilities.

Methods  We match hospital-level data on EHR use/functionality with operating costs and facility characteristics to perform linear regressions with hospital- and time-fixed effects on a panel of 1,596 U.S. hospitals observed annually from 2016 to 2019. Our dependent variables are the logs of the various hospital operating cost categories, and alternative metrics for EHR use/functionality serve as the primary independent variables of interest. Data on EHR use/functionality are retrieved from the American Hospital Association's (AHA) Annual Survey of Hospitals Information Technology (IT) Supplement, and hospital operating cost and characteristic data are retrieved from the American Hospital Directory. We include only hospitals classified as “general medical and surgical,” removing specialty hospitals.

Results  Our results suggest, first, that increasing levels of EHR functionality are associated with hospital operating cost reductions. Second, that these significant cost reductions are exclusively seen in urban hospitals, with the associated coefficient suggesting cost savings of 0.14% for each additional EHR function. Third, that urban EHR-related cost reductions are driven by general/ancillary and outpatient costs. Finally, that a wide variety of EHR functions are associated with cost reductions for urban facilities, while no EHR function is associated with significant cost reductions in rural locations.

Conclusion  Increasing EHR functionality is associated with significant hospital operating cost reductions in urban locations. These results do not hold across geographies, and policies to promote greater EHR functionality in rural hospitals will likely not lead to short-term cost reductions.

The "Ecosystem as a Service (EaaS)" approach to advance clinical artificial intelligence (cAI)

The application of machine learning and artificial intelligence to clinical settings for prevention, diagnosis, treatment, and the improvement of clinical care have been demonstrably cost-effective. However, current clinical AI (cAI) support tools are predominantly created by non-domain experts and algorithms available in the market have been criticized for the lack of transparency behind their creation. To combat these challenges, the Massachusetts Institute of Technology Critical Data (MIT-CD) consortium, an affiliation of research labs, organizations, and individuals that contribute to research in and around data that has a critical impact on human health, has iteratively developed the "Ecosystem as a Service (EaaS)" approach, providing a transparent education and accountability platform for clinical and technical experts to collaborate and advance cAI. The EaaS approach provides a range of resources, from open-source databases and specialized human resources to networking and collaborative opportunities. While mass deployment of the ecosystem still faces several hurdles, here we discuss our initial implementation efforts. We hope this will promote further exploration and expansion of the EaaS approach, while also informing or realizing policies that will accelerate multinational, multidisciplinary, and multisectoral collaborations in cAI research and development, and provide localized clinical best practices for equitable healthcare access.

Value of the Electronic Medical Record for Hospital Care: Update From the Literature

Background

Electronic records could improve quality and efficiency of health care. National and international bodies propagate this belief worldwide. However, the evidence base concerning the effects and advantages of electronic records is questionable. The outcome of health care systems is influenced by many components, making assertions about specific types of interventions difficult. Moreover, electronic records itself constitute a complex intervention offering several functions with possibly positive as well as negative effects on the outcome of health care systems.

Objective

The aim of this review is to summarize empirical studies about the value of electronic medical records (EMRs) for hospital care published between 2010 and spring 2019.

Methods

The authors adopted their method from a series of literature reviews. The literature search was performed on MEDLINE with “Medical Record System, Computerized” as the essential keyword. The selection process comprised 2 phases looking for a consent of both authors. Starting with 1345 references, 23 were finally included in the review. The evaluation combined a scoring of the studies’ quality, a description of data sources in case of secondary data analyses, and a qualitative assessment of the publications’ conclusions concerning the medical record’s impact on quality and efficiency of health care.

Results

The majority of the studies stemmed from the United States (19/23, 83%). Mostly, the studies used publicly available data (“secondary data studies”; 17/23, 74%). A total of 18 studies analyzed the effect of an EMR on the quality of health care (78%), 16 the effect on the efficiency of health care (70%). The primary data studies achieved a mean score of 4.3 (SD 1.37; theoretical maximum 10); the secondary data studies a mean score of 7.1 (SD 1.26; theoretical maximum 9). From the primary data studies, 2 demonstrated a reduction of costs. There was not one study that failed to demonstrate a positive effect on the quality of health care. Overall, 9/16 respective studies showed a reduction of costs (56%); 14/18 studies showed an increase of health care quality (78%); the remaining 4 studies missed explicit information about the proposed positive effect.

Conclusions

This review revealed a clear evidence about the value of EMRs. In addition to an awesome majority of economic advantages, the review also showed improvements in quality of care by all respective studies. The use of secondary data studies has prevailed over primary data studies in the meantime. Future work could focus on specific aspects of electronic records to guide their implementation and operation.

A longitudinal time and motion study quantifying how implementation of an electronic medical record influences hospital nurses' care delivery

AIM BACKGROUND

Many health care services are implementing or planning to undergo digital transformation to keep pace with increasing Electronic Medical Record (EMR) functionality. The aim of this study was to objectively measure nursing care delivery before and following introduction of an EMR.

DESIGN AND METHODS

An extensive program of work to expand an EMR across our health service using a 'big bang' methodology was undertaken. The program incorporated digital care delivery workflows including physiological observations, clinical notes and closed loop medication management. The validated Work Observation Method by Activity Timing (WOMBAT) method was applied to undertake a direct observational time and motion study of nurses' work in a major Australian hospital immediately prior to and six months following the introduction of a full clinical EMR.

RESULTS

Time and motion results were from observing approximately one week of nursing time pre (paper) to six months post (EMR) implementation. A non-significant 6.4% increase in the proportion of time spent on direct care was observed when using the EMR with a statistically significant increase in mean time per direct care task (2.5 min vs 3.9 min, p = 0.001). The proportion of time spent on medication-related activities did not significantly change although the average time per task rose from 2.0 to 2.9 min (p = 0.008). A significant reduction in proportion of time spent in transit and indirect care tasks when using the electronic workflows was reported. No statistically significant changes to the proportions of time spent on professional communication, direct care or documentation were observed.

CONCLUSIONS

Successful EMR implementation is possible without adversely affecting allocation of nursing time. Our findings from deploying a large scale EMR across all healthcare craft groups and workflows have described for nurses that an EMR enables them to spend longer with patients per direct care episode and use their time on other activities more effectively.

Electronic medical records and primary care quality: Evidence from Manitoba

Improvements in quality of care through supporting decision-making processes and increased efficiency have prompted widespread implementation of electronic medical records (EMRs) in Canada. Using a set of indicators of preventive care, chronic disease management, and hospitalizations due to ambulatory care sensitive conditions (ACSC), this study measures the effect of EMR adoption on quality of primary care measures. Population-based data for the Canadian province of Manitoba are used in a difference-in-differences approach with patient- and time-fixed effects. Evidence of changes in the selected quality-of-care indicators is weak, with preventive care, management of asthma, and hospitalizations showing no significant change due to EMR adoption. A statistically significant increase in the quality of diabetes care was found for EMR users, changes being larger for late EMR adopters which is possibly explained by a network effect. This research demonstrates that measuring whether EMRs prompt changes in the quality of care confronts serious challenges. The rapid evolution and gradual adoption of EMR technology, the inevitable learning/acceptance process by individual health practitioners, and its potential reflection on different patient populations create unmeasurable variables that confound EMRs' impact. This study also underscores the importance of data development to support the economic value of EMRs.

Sustaining Innovations in Complex Health Care Environments: A Multiple-Case Study of Rapid Response Teams

OBJECTIVES

Rapid response teams (RRTs) are one innovation previously deployed in U.S. hospitals with the goal to improve the quality of care. Sustaining RRTs is important to achieve the desired implementation outcomes, reduce the risk of program investment losses, and prevent employee disillusionment and dissatisfaction. This study sought to examine factors that do and do not support the sustainability of RRTs.

METHODS

The study was conceptually guided by an adapted version of the Planning Model of Sustainability. A multiple-case study was conducted using a purposive sample of 2 hospitals with high RRT sustainability scores and 2 hospitals with low RRT sustainability scores. Data collection methods included (a) a hospital questionnaire that was completed by a nurse administrator at each hospital; (b) semistructured interviews with leaders, RRT members, and those activating RRT calls; and (c) a review of internal documents. Quantitative data were analyzed using descriptive statistics; qualitative data were analyzed using content analysis.

RESULTS

Few descriptive differences were found between hospitals. However, there were notable differences in the operationalization of certain factors between high- and low-sustainability hospitals. Additional sustainability factors other than those captured by the Planning Model of Sustainability were also identified.

CONCLUSIONS

The sustainability of RRTs is optimized through effective operationalization of organizational and project design and implementation factors. Two additional factors-individual and team characteristics-should be included in the Planning Model of Sustainability and considered as potential facilitators (or inhibitors) of RRT sustainability.

Data-Driven Activities Involving Electronic Health Records: An Activity and Task Analysis Framework for Interactive Visualization Tools

Electronic health records (EHRs) can be used to make critical decisions, to study the effects of treatments, and to detect hidden patterns in patient histories. In this paper, we present a framework to identify and analyze EHR-data-driven tasks and activities in the context of interactive visualization tools (IVTs)—that is, all the activities, sub-activities, tasks, and sub-tasks that are and can be supported by EHR-based IVTs. A systematic literature survey was conducted to collect the research papers that describe the design, implementation, and/or evaluation of EHR-based IVTs that support clinical decision-making. Databases included PubMed, the ACM Digital Library, the IEEE Library, and Google Scholar. These sources were supplemented by gray literature searching and reference list reviews. Of the 946 initially identified articles, the survey analyzes 19 IVTs described in 24 articles that met the final selection criteria. The survey includes an overview of the goal of each IVT, a brief description of its visualization, and an analysis of how sub-activities, tasks, and sub-tasks blend and combine to accomplish the tool’s main higher-level activities of interpreting, predicting, and monitoring. Our proposed framework shows the gaps in support of higher-level activities supported by existing IVTs. It appears that almost all existing IVTs focus on the activity of interpreting, while only a few of them support predicting and monitoring—this despite the importance of these activities in assisting users in finding patients that are at high risk and tracking patients’ status after treatment.

Health Information Technology Adoption and Clinical Performance in Federally Qualified Health Centers

A national sample (N = 982) of federally qualified health centers (FQHCs) for the period 2011-2016 was examined regarding the relationship between the age and extent of health information technology (HIT) use and clinical performance. We found that each additional year of HIT use was associated with an approximate 4 percent increase in both process and outcome measures of clinical performance. Furthermore, FQHCs that fully adopted HIT had 7 percent higher clinical performance on hypertension control than those that did not adopt HIT. This study's findings can assist stakeholders to make informed decisions for improving care and sustaining a competitive advantage.

Electronic health records systems and hospital clinical performance: a study of nationwide hospital data

OBJECTIVE

Electronic health records (EHRs) were expected to yield numerous benefits. However, early studies found mixed evidence of this. We sought to determine whether widespread adoption of modern EHRs in the US has improved clinical care.

METHODS

We studied hospitals reporting performance measures from 2008-2015 in the Centers for Medicare and Medicaid Services Hospital Compare database that also reported having an EHR in the American Hospital Association 2015 IT supplement. Using interrupted time-series analysis, we examined the association of EHR implementation, EHR vendor, and Meaningful Use status with 11 process measures and 30-day hospital readmission and mortality rates for heart failure, pneumonia, and acute myocardial infarction.

RESULTS

A total of 1246 hospitals contributed 8222 hospital-years. Compared to hospitals without EHRs, hospitals with EHRs had significant improvements over time on 5 of 11 process measures. There were no substantial differences in readmission or mortality rates. Hospitals with CPSI EHR systems performed worse on several process and outcome measures. Otherwise, we found no substantial improvements in process measures or condition-specific outcomes by duration of EHR use, EHR vendor, or a hospital's Meaningful Use Stage 1 or Stage 2 status.

CONCLUSION

In this national study of hospitals with modern EHRs, EHR use was associated with better process of care measure performance but did not improve condition-specific readmission or mortality rates regardless of duration of EHR use, vendor choice, or Meaningful Use status. Further research is required to understand why EHRs have yet to improve standard outcome measures and how to better realize the potential benefits of EHR systems.

A regulatory perspective on the influence of health information technology on organisational quality and safety in England

Health information technology can transform and enhance the quality and safety of care, but it may also introduce new risks. This study analysed 130 healthcare regulator inspection reports and organisational digital maturity scores in order to characterise the impact of health information technology on quality and safety from a regulatory perspective. Although digital maturity and the positive use of health information technology are significantly associated with overall organisational quality, the negative effects of health information technology are frequently and more commonly identified by regulators. The poor usability of technology, lack of easy access to systems and data and the incorrect use of health information technology are the most commonly identified areas adversely affecting quality and safety. There is a need to understand the full risks and benefits of health information technology from the perspective of all stakeholders, including patients, end-users, providers and regulators in order to best inform future practice and regulation.

Use, cost, and digital divide in online public health care: lessons from Denmark

Purpose

The purpose of this paper is to enhance the knowledge about the use of online communication between patients and health-care professionals in public health care. The study explores digital divide gaps and the impacts of online communication on the overall costs of health care.

Design/methodology/approach

This study focuses on online health care in Denmark. The authors rely on population data from 3,500 e-visits (e-mail consultations) between patients and general practitioners (GPs) from 2009 to 2015. Additionally, they include survey data on the use of the internet to search for health-related information.

Findings

The analysis of the Danish data reveals a rapid uptake in the use of the internet to search for health-related information and a three-fold increase in e-visits from 2009 to 2015. The results show that the digital divide gaps exist also in the online health-care communication. Further, the study findings suggest that enforced supply of online communication between GPs and patients does not alleviate the costs. Rather, the number of visits to GPs has not been decreased significantly and health-care costs showing a marginal increase.

Research limitations/implications

Further data should be collected and analyzed to explore the impacts of other institutional factors and population cohort on the digital divide and healthcare costs. Also, it is difficult to estimate whether the increased use of online health care in the long run lead to lowering overall health-care costs. While the internal validity of the study is high due to the use of population data, the external validity is lower as the study results are based on the data collected in Denmark only.

Practical implications

The study offers important input for practice. First, leaders in government might reconsider how they can control the health-care costs when opening online channels for communication between patients and doctors. Second, concerns about digital divide issues remains, but the study suggests that the uptake of e-visits does not widen the socio-economic, gender or age gaps. For health policy concern, this is encouraging news to lead to an increasing push of online communication.

Social implications

The dynamics of online health-care communication may lead to mixed results and unexpected impacts on overall health-care costs.

Originality/value

The paper offers new insights in the impacts of mandatory supply of digital services. The Danish push-strategy has led to an enforced supply of e-visits and a rapid growing use of the online health care without widening digital divide but at the risk of potential increasing the overall costs.

Evaluating the impact of organisational digital maturity on clinical outcomes in secondary care in England

All healthcare systems are increasingly reliant on health information technology to support the delivery of high-quality, efficient and safe care. Data on its effectiveness are however limited. We therefore sought to examine the impact of organisational digital maturity on clinical outcomes in secondary care within the English National Health Service. We conducted a retrospective analysis of routinely collected administrative data for 13,105,996 admissions across 136 hospitals in England from 2015 to 2016. Data from the 2016 NHS Clinical Digital Maturity Index were used to characterise organisational digital maturity. A multivariable regression model including 12 institutional covariates was utilised to examine the relationship between one measure of organisational digital maturity and five key clinical outcome measures. There was no significant relationship between organisational digital maturity and risk-adjusted 30-day mortality, 28-day readmission rates or complications of care. In multivariable analysis risk-adjusted long length of stay and harm-free care were significantly related to aspects of organisational digital maturity; digitally mature hospitals may not only deliver more harm-free care episodes but also may have a significantly increased risk of patients experiencing a long length of stay. Organisational digital maturity is to some extent related to selected clinical outcomes in secondary care in England. Digital maturity is, however, also strongly linked to other institutional factors that likely play a greater role in influencing clinical outcomes. There is a need to better understand how health IT impacts care delivery and supports other drivers of hospital quality.

Orthopaedic Resident Use of an Electronic Medical Record Template Does Not Improve Documentation for Pediatric Supracondylar Humerus Fractures

INTRODUCTION

Pediatric supracondylar humerus fractures are associated with a high incidence of nerve injury. Therefore, it is imperative that documentation be complete and accurate. This investigation compares orthopaedic resident history and physical (H&P) documentation of pediatric supracondylar fractures for completeness and accuracy with and without the use of an electronic medical record template.

METHODS

The electronic medical record H&P documentation of 119 supracondylar humerus fractures surgically treated at a single pediatric institution was retrospectively reviewed. Templated and nontemplated groups were compared for documentation completeness and accuracy. Definitive diagnosis of a nerve palsy was made by a supervising orthopaedic attending surgeon.

RESULTS

Forty-two cases had a templated H&P and 77 did not. The H&P documentation in the templated group was markedly more complete than that in the nontemplated group. However, the accuracy of the H&P documentation to identify nerve palsy was not statistically different between the two groups. Overall, the voluntary use of the orthopaedic template declined over time.

CONCLUSION

Resident use of an orthopaedic template for documenting the H&P of pediatric supracondylar humerus fractures compared with nontemplated notes resulted in more complete documentation but only comparable accuracy.

LEVEL OF EVIDENCE

III.

Balancing Quality Healthcare Services and Costs Through Collaborative Leadership

EXECUTIVE SUMMARY

This review assesses the effectiveness of collaborative leadership strategies in balancing quality healthcare services and costs. Quantitative analysis of 39 studies answered research questions to identify collaborative leadership strategies employed by healthcare managers to address the cost of care, determine the most effective strategies for managing this cost, and evaluate how collaborative leadership's cost-reduction strategies affect quality of care. The intrahospital collaboration strategy was noted to be the most frequently used strategy (53.8%). The other strategies included patient-based collaboration (41.0%) and interorganizational collaboration (17.9%). The patient-based collaborative strategy offered significantly higher cost-reduction effectiveness (31.9% ± 6.005). The cost effectiveness of the intrahospital collaboration (25.3% ± 2.014) and interorganizational collaboration strategy (20.2% ± 4.229) were also significant. The adoption of the patient-based collaboration strategy was associated with enhanced quality of healthcare (62.5%), while the interorganizational collaboration strategy had a greater proportion of noneffect on quality of services (71.4%). Therefore, healthcare leaders should facilitate the adoption of patient-based and interorganizational collaboration strategies to manage healthcare costs.

Administrative costs in health care-A scoping review

BACKGROUND

Administrative costs (AC) are a relevant spending category in health care, and several approaches exist on how to define and measure them. Based on available AC studies, this paper aims to provide a map for this multifaceted research topic.

METHODS

A scoping review was conducted using the databases MEDLINE, EconLit, and Business Source Premier. Literature was screened focussing on the research question: What is known about the methodology of AC research from scientific publications?

RESULTS

Definition concepts mostly rely on national cost documentations. The international cost reporting framework of the Systems of Health Accounts was a critical reference point in six studies. Indications on how to operationalise AC independently from periodical cost reports were suggested by ten publications. In this context, time and full time equivalents are the most common cost measurements.

CONCLUSIONS

The results indicate a lack of evidence regarding patients' perceptions of administrative issues in health care. Also, research on administrative impact on working conditions for health care employees beyond hospitals and physicians' offices is underrepresented. A systematic approach to reporting AC studies is needed. Reporting should include the appointment of entities actually empowered to change administrative resource usage. This would help to promote principles of a balanced administration.

How Do Experienced Physicians Access and Evaluate Laboratory Test Results for the Chronic Patient? A Qualitative Analysis

BACKGROUND

Electronic health records may present laboratory test results in a variety of ways. Little is known about how the usefulness of different visualizations of laboratory test results is influenced by the complex and varied process of clinical decision making.

OBJECTIVE

The purpose of this study was to investigate how clinicians access and utilize laboratory test results when caring for patients with chronic illness.

METHODS

We interviewed 10 attending physicians about how they access and assess laboratory tests when following up patients with chronic illness. The interviews were audio-recorded, transcribed verbatim, and analyzed qualitatively.

RESULTS

Informants preferred different visualizations of laboratory test results, depending on what aspects of the data they were interested in. As chronic patients may have laboratory test results that are permanently outside standardized reference ranges, informants would often look for significant change, rather than exact values. What constituted significant change depended on contextual information (e.g., the results of other investigations, intercurrent diseases, and medical interventions) spread across multiple locations in the electronic health record. For chronic patients, the temporal relations between data could often be of special interest. Informants struggled with finding and synthesizing fragmented information into meaningful overviews.

CONCLUSION

The presentation of laboratory test results should account for the large variety of associated contextual information needed for clinical comprehension. Future research is needed to improve the integration of the different parts of the electronic health record.

Health information technology in ambulatory care in a developing country

Background

Physicians need to apply new technologies in ambulatory care. At present, with regard to the extended use of information technology in other departments in Iran it has yet to be considerably developed by physicians and clinical technicians in the health department.

Objective

To determine the rate of use of health information technology in the clinics of specialist- and subspecialist physicians in Semnan city, Iran.

Methods

This was a 2016 cross-sectional study conducted in physicians’ offices of Semnan city in Iran. All physicians’ offices in Semnan (130) were studied in this research. A researcher made and Likert-type questionnaire was designed, and consisted of two sections: the first section included demographic items and the second section consisted of four subscales (telemedicine, patient’s safety, electronic patient record, and electronic communications). In order to determine the validity, the primary questionnaire was reviewed by one medical informatics- and two health information management experts from Semnan University of Medical Sciences. Utilizing the experts’ suggestions, the questionnaire was rewritten and became more focused. Then the questionnaire was piloted on forty participants, randomly selected from different physicians’ offices. Participants in the pilot study were excluded from the study. Cronbach’s alpha was used to calculate the reliability of the instruments. Finally, SPSS version 16 was used to conduct descriptive and inferential statistics.

Results

The minimum mean related to the physicians’ use of E-mail services for the purpose of communicating with the patients, the physicians’ use of computer-aided diagnostics to diagnose the patients’ illnesses, and the level of the physicians’ access to the electronic medical record of patients in the other treatment centers were 2.01, 3.58, and 1.43 respectively. The maximum mean score was related to the physicians’ use of social networks to communicate with other physicians (3.64). The study showed that the physicians used less computerized systems in their clinic for the purpose of managing their patients’ safety and there was a significant difference between the mean of the scores (p<0.001)

Conclusion

The results showed that the physicians used some aspects of health information technology for the reduction of medical risks and increase of the patient’s safety, by collecting the medical data of patients and the rapid and apropos recovering of them for adaptation of clinical decisions.

Association between Health Information Technology and Case Mix Index

Objectives

Health information technology (IT) can assist healthcare providers in ordering medication and adhering to guidelines while improving communication among providers and the quality of care. However, the relationship between health IT and Case Mix Index (CMI) has not been thoroughly investigated; therefore, this study aimed to clarify this relationship.

Methods

To examine the effect of health IT on CMI, a generalized estimation equation (GEE) was applied to two years of California hospital data.

Results

We found that IT was positively associated with CMI, indicating that increased IT adoption could lead to a higher CMI or billing though DRG up-coding. This implies that hospitals' revenue could increase around $40,000 by increasing IT investment by 10%.

Conclusions

The positive association between IT and CMI implies that IT adoption itself could lead to higher patient billings. Generally, a higher CMI in a hospital indicates that the hospital provides expensive services with higher coding and therefore receives more money from patients. Therefore, measures to prevent upcoding through IT systems should be implemented.

Community-acquired pneumonia management and outcomes in the era of health information technology

Pneumonia continues to be a leading cause of hospitalization and mortality. Implementation of health information technology (HIT) can lead to cost savings and improved care. In this review, we examine the literature on the use of HIT in the management of community-acquired pneumonia. We also discuss barriers to adoption of technology in managing pneumonia, the reliability and quality of electronic health data in pneumonia research, how technology has assisted pneumonia diagnosis and outcomes research. The goal of using HIT is to develop and deploy generalizable, real-time, computerized clinical decision support integrated into usual pneumonia care. A friendly user interface that does not disrupt efficiency and demonstrates improved clinical outcomes should result in widespread adoption.

Sustaining Health Care Interventions to Achieve Quality Care: What We Can Learn From Rapid Response Teams

Rapid response team (RRT) adoption and implementation are associated with improved quality of care of patients who experience an unanticipated medical emergency. The sustainability of RRTs is vital to achieve long-term benefits of these teams for patients, staff, and hospitals. Factors required to achieve RRT sustainability remain unclear. This study examined the relationship between sustainability elements and RRT sustainability in hospitals that have previously implemented RRTs.

Making electronic health records support quality management: A narrative review

BACKGROUND

Since the 1990s many hospitals in the OECD countries have introduced electronic health record (EHR) systems. A number of studies have examined the factors impinging on EHR implementation. Others have studied the clinical efficacy of EHR. However, only few studies have explored the (intermediary) factors that make EHR systems conducive to quality management (QM).

OBJECTIVE

Undertake a narrative review of existing studies in order to identify and discuss the factors conducive to making EHR support three dimensions of QM: clinical outcomes, managerial monitoring and cost-effectiveness.

METHOD

A narrative review of Web of Science, Cochrane, EBSCO, ProQuest, Scopus and three Nordic research databases.

LIMITATION

most studies do not specify the type of EHR examined.

RESULTS

39 studies were identified for analysis. 10 factors were found to be conducive to make EHR support QM. However, the contribution of EHR to the three specific dimensions of QM varied substantially. Most studies (29) included clinical outcomes. However, only half of these reported EHR to have a positive impact. Almost all the studies (36) dealt with the ability of EHR to enhance managerial monitoring of clinical activities, the far majority of which showed a positive relationship. Finally, only five dealt with cost-effectiveness of which two found positive effects.

DISCUSSION AND CONCLUSION

The findings resonates well with previous reviews, though two factors making EHR support QM seem new, namely: political goals and strategies, and integration of guidelines for clinical conduct. Lacking EHR type specification and diversity in study method imply that there is a strong need for further research on the factors that may make EHR may support QM.

An Ethnographic Study of Health Information Technology Use in Three Intensive Care Units

OBJECTIVES

To identify the impact of a full suite of health information technology (HIT) on the relationships that support safety and quality among intensive care unit (ICU) clinicians.

DATA SOURCES

A year-long comparative ethnographic study of three academic ICUs was carried out. A total of 446 hours of observational data was collected in the form of field notes. A subset of these observations-134 hours-was devoted to job-shadowing individual clinicians and conducting a time study of their HIT usage.

PRINCIPAL FINDINGS

Significant variation in HIT implementation rates and usage was noted. Average HIT use on the two "high-use" ICUs was 49 percent. On the "low-use" ICU, it was 10 percent. Clinicians on the high-use ICUs experienced "silo" effects with potential safety and quality implications. HIT work was associated with spatial, data, and social silos that separated ICU clinicians from one another and their patients. Situational awareness, communication, and patient satisfaction were negatively affected by this siloing.

CONCLUSIONS

HIT has the potential to accentuate social and professional divisions as clinical communications shift from being in-person to electronically mediated. Socio-technically informed usability testing is recommended for those hospitals that have yet to implement HIT. For those hospitals already implementing HIT, we suggest rapid, locally driven qualitative assessments focused on developing solutions to identified gaps between HIT usage patterns and organizational quality goals.

Adverse inpatient outcomes during the transition to a new electronic health record system: observational study

OBJECTIVE

 To assess the short term association of inpatient implementation of electronic health records (EHRs) with patient outcomes of mortality, readmissions, and adverse safety events.

DESIGN

 Observational study with difference-in-differences analysis.

SETTING

 Medicare, 2011-12.

PARTICIPANTS

 Patients admitted to 17 study hospitals with a verifiable "go live" date for implementation of inpatient EHRs during 2011-12, and 399 control hospitals in the same hospital referral region.

MAIN OUTCOME MEASURES

 All cause readmission within 30 days of discharge, all cause mortality within 30 days of admission, and adverse safety events as defined by the patient safety for selected indicators (PSI)-90 composite measure among Medicare beneficiaries admitted to one of these hospitals 90 days before and 90 days after implementation of the EHRs (n=28 235 and 26 453 admissions), compared with the control group of all contemporaneous admissions to hospitals in the same hospital referral region (n=284 632 and 276 513 admissions). Analyses were adjusted for beneficiaries' sociodemographic and clinical characteristics.

RESULTS

 Before and after implementation, characteristics of admissions were similar in both study and control hospitals. Among study hospitals, unadjusted 30 day mortality (6.74% to 7.15%, P=0.06) and adverse safety event rates (10.5 to 11.4 events per 1000 admissions, P=0.34) did not significantly change after implementation of EHRs. There was an unadjusted decrease in 30 day readmission rates, from 19.9% to 19.0% post-implementation (P=0.02). In difference-in-differences analysis, however, there was no significant change in any outcome between pre-implementation and post-implementation periods (all P≥0.13).

CONCLUSIONS

 Despite concerns that implementation of EHRs might adversely impact patient care during the acute transition period, we found no overall negative association of such implementation on short term inpatient mortality, adverse safety events, or readmissions in the Medicare population across 17 US hospitals.

A Survey of Hospitals That Participated in a Statewide Collaborative to Implement and Sustain Rapid Response Teams

OBJECTIVES

To determine the level of sustainability of rapid response teams (RRTs) among a group of hospitals that participated in a statewide collaborative to implement and sustain RRTs.

SETTING AND SAMPLE

Fifty-six hospitals located in a southeastern state in the United States participated in a statewide 9-month collaborative that provided organization leaders with resources to implement and sustain RRTs. Thirty-three of these hospitals completed the electronic survey. Two hospitals were excluded because of missing data.

MEASUREMENT

The RRT-Institutionalization Scale (RRT-IS), adapted from the Level of Institutionalization Scale, measured the degree of institutionalization (i.e., passages, routines, and niche saturation) across four subsystems: production, maintenance, supportive, and managerial.

RESULTS

Thirty-one hospitals participated (response rate 55%). Rapid response team sustainability levels ranged from 1.0 to 5.98 (mean = 3.78, 95% CI = 3.40-4.17). The highest sustainability score was reported in the managerial subsystem (median = 5.3, IQR = 4.5-7.33), and the lowest score was reported in the supportive subsystem (median = 1.0, IQR = 1.0-2.0).

CONCLUSIONS

Rapid response team sustainability levels varied across hospitals in the collaborative. Different levels of sustainability were also observed across organizational subsystems. The lack of resources, staff, and dedicated funds hampered organizations' sustainability efforts.

A Mobile, Collaborative, Real Time Task List for Inpatient Environments

BACKGROUND

Inpatient teams commonly track their tasks using paper checklists that are not shared between team members. Team members frequently communicate redundantly in order to prevent errors.

METHODS

We created a mobile, collaborative, real-time task list application on the iOS platform. The application listed tasks for each patient, allowed users to check them off as completed, and transmitted that information to all other team members. In this report, we qualitatively describe our experience designing and piloting the application with an inpatient pediatric ward team at an academic pediatric hospital.

RESULTS

We successfully created the tasklist application, however team members showed limited usage.

CONCLUSION

Physicians described that they preferred the immediacy and familiarity of paper, and did not experience an efficiency benefit when using the electronic tasklist.

Investment subsidies and the adoption of electronic medical records in hospitals

In February 2009 the U.S. Congress unexpectedly passed the Health Information Technology for Economic and Clinical Health Act (HITECH). HITECH provides up to $27 billion to promote adoption and appropriate use of Electronic Medical Records (EMR) by hospitals. We measure the extent to which HITECH incentive payments spurred EMR adoption by independent hospitals. Adoption rates for all independent hospitals grew from 48 percent in 2008 to 77 percent by 2011. Absent HITECH incentives, we estimate that the adoption rate would have instead been 67 percent in 2011. When we consider that HITECH funds were available for all hospitals and not just marginal adopters, we estimate that the cost of generating an additional adoption was $48 million. We also estimate that in the absence of HITECH incentives, the 77 percent adoption rate would have been realized by 2013, just 2 years after the date achieved due to HITECH.

Impact of Heath Information Technology on the Quality of Patient Care

OBJECTIVE

To examine the relationships among Electronic Health Record (EHR) adoption and adverse outcomes and satisfaction in hospitalized patients.

MATERIALS AND METHODS

This secondary analysis of cross sectional data was compiled from four sources: (1) State Inpatient Database from the Healthcare Cost Utilization Project; (2) Healthcare Information and Management Systems Society (HIMSS) Dorenfest Institute; (3) Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) and (4) New Jersey nurse survey data. The final analytic sample consisted of data on 854,258 adult patients discharged from 70 New Jersey hospitals in 2006 and 7,679 nurses working in those same hospitals. The analytic approach used ordinary least squares and multiple regression models to estimate the effects of EHR adoption stage on the delivery of nursing care and patient outcomes, controlling for characteristics of patients, nurses, and hospitals.

RESULTS

Advanced EHR adoption was independently associated with fewer patients with prolonged length of stay and seven-day readmissions. Advanced EHR adoption was not associated with patient satisfaction even when controlling for the strong relationships between better nursing practice environments, particularly staffing and resource adequacy, and missed nursing care and more patients reporting "Top-Box," satisfaction ratings.

CONCLUSIONS

This innovative study demonstrated that advanced stages of EHR adoption show some promise in improving important patient outcomes of prolonged length of stay and hospital readmissions. Strongly evident by the relationships among better nursing work environments, better quality nursing care, and patient satisfaction is the importance of supporting the fundamentals of quality nursing care as technology is integrated into practice.

Modest Associations Between Electronic Health Record Use and Acute Myocardial Infarction Quality of Care and Outcomes: Results From the National Cardiovascular Data Registry

BACKGROUND

In 2009, national legislation promoted wide-spread adoption of electronic health records (EHRs) across US hospitals; however, the association of EHR use with quality of care and outcomes after acute myocardial infarction (AMI) remains unclear.

METHODS AND RESULTS

Data on EHR use were collected from the American Hospital Association Annual Surveys (2007-2010) and data on AMI care and outcomes from the National Cardiovascular Data Registry Acute Coronary Treatment and Interventions Outcomes Network Registry-Get With The Guidelines. Comparisons were made between patients treated at hospitals with fully implemented EHR (n=43 527), partially implemented EHR (n=72 029), and no EHR (n=9270). Overall EHR use increased from 82.1% (183/223) hospitals in 2007 to 99.3% (275/277) hospitals in 2010. Patients treated at hospitals with fully implemented EHRs had fewer heparin overdosing errors (45.7% versus 72.8%; P<0.01) and a higher likelihood of guideline-recommended care (adjusted odds ratio, 1.40 [confidence interval, 1.07-1.84]) compared with patients treated at hospitals with no EHR. In non-ST-segment-elevation AMI, fully implemented EHR use was associated with lower risk of major bleeding (adjusted odds ratio, 0.78 [confidence interval, 0.67-0.91]) and mortality (adjusted odds ratio, 0.82 [confidence interval, 0.69-0.97]) compared with no EHR. In ST-segment-elevation MI, outcomes did not significantly differ by EHR status.

CONCLUSIONS

EHR use has risen to high levels among hospitals in the National Cardiovascular Data Registry. EHR use was associated with less frequent heparin overdosing and modestly greater adherence to acute MI guideline-recommended therapies. In non-ST-segment-elevation MI, slightly lower adjusted risk of major bleeding and mortality were seen in hospitals implemented with full EHRs; however, in ST-segment-elevation MI, differences in outcomes were not seen.

EHR Adoption and Hospital Performance: Time-Related Effects

OBJECTIVE

To assess whether, 5 years into the HITECH programs, national data reflect a consistent relationship between EHR adoption and hospital outcomes across three important dimensions of hospital performance.

DATA SOURCES/STUDY SETTING

Secondary data from the American Hospital Association and CMS (Hospital Compare and EHR Incentive Programs) for nonfederal, acute-care hospitals (2009-2012).

STUDY DESIGN

We examined the relationship between EHR adoption and three hospital outcomes (process adherence, patient satisfaction, efficiency) using ordinary least squares models with hospital fixed effects. Time-related effects were assessed through comparing the impact of EHR adoption pre (2008/2009) versus post (2010/2011) meaningful use and by meaningful use attestation cohort (2011, 2012, 2013, Never). We used a continuous measure of hospital EHR adoption based on the proportion of electronic functions implemented.

DATA COLLECTION/EXTRACTION METHODS

We created a panel dataset with hospital-year observations.

PRINCIPAL FINDINGS

Higher levels of EHR adoption were associated with better performance on process adherence (0.147; p < .001) and patient satisfaction (0.118; p < .001), but not efficiency (0.01; p = .78). For all three outcomes, there was a stronger, positive relationship between EHR adoption and performance in 2010/2011 compared to 2008/2009. We found mixed results based on meaningful use attestation cohort.

CONCLUSIONS

Performance gains associated with EHR adoption are apparent in more recent years. The large national investment in EHRs appears to be delivering more consistent benefits than indicated by earlier national studies.

Quality Outcomes in the Surgical Intensive Care Unit after Electronic Health Record Implementation

BACKGROUND

The electronic health record (EHR) is increasingly viewed as a means to provide more coordinated, patient-centered care. Few studies consider the impact of EHRs on quality of care in the intensive care unit (ICU) setting.

OBJECTIVES

To evaluate key quality measures of a surgical intensive care unit (SICU) following implementation of the Epic EHR system in a tertiary hospital.

METHODS

A retrospective chart review was undertaken to record quality indicators for all patients admitted to the SICU two years before and two years after EHR implementation. Data from the twelve-month period of transition to EHR was excluded. We collected length of stay, mortality, central line associated blood stream infection (CLABSI) rates, Clostridium difficile (C. diff.) colitis rates, readmission rates, and number of coded diagnoses. To control for variation in the patient population over time, the case mix indexes (CMIs) and APACHE II scores were also analyzed.

RESULTS

There was no significant difference in length of stay, C. diff. colitis, readmission rates, or case mix index before and after EHR. After EHR implementation, the rate of central line blood stream infection (CLABSI) per 1 000 catheter days was 85% lower (2.16 vs 0.39; RR, 0.18; 95% CI, 0.05 to 0.61, p < .005), and SICU mortality was 28% lower (12.2 vs 8.8; RR, 1.35; 95% CI, 1.06 to 1.71, p < .01). Moreover, after EHR there was a significant increase in the average number of coded diagnoses from 17.8 to 20.8 (p < .000).

CONCLUSIONS

EHR implementation was statistically associated with reductions in CLABSI rates and SICU mortality. The EHR had an integral role in ongoing quality improvement endeavors which may explain the changes in CLABSI and mortality, and this invites further study of the impact of EHRs on quality of care in the ICU.

The Association between eHealth Capabilities and the Quality and Safety of Health Care in the Netherlands: Comparison of HIMSS Analytics EMRAM data with Elsevier's 'The Best Hospitals' data

OBJECTIVE

To test the hypothesis that advanced electronic medical record (EMR) capabilities are associated with better quality and safety of hospital care.

METHODS AND FINDINGS

We used data from the HIMSS Analytics EMR Adoption Model (EMRAM(SM)) to measure the adoption and use of information technology in Dutch hospitals. To measure the quality and safety of healthcare in Dutch Hospitals we used select data from the publicly available basic set and the safety set of the Health Care Inspectorate (IGZ) and the Dutch Health Care Transparency Program 'Zichtbare Zorg' (ZIZO) program. The quality and safety measures selected reflect the measures used to score Dutch hospitals as presented in Elsevier's annual 'The Best Hospitals' publication. The scores of this publication are based upon 542 of the 1516 available indicators from this basic set and safety set. Almost all indicators from the hospital-wide indicator sets are included in the selection, as are a large portion of indicators for acute care delivered by all hospitals. Of the 84 non-academic hospitals in the Netherlands, 67 (80 %) were included in this study.

RESULTS

There is no statistically significant association found between a hospital's EMRAM score and their overall quality/safety performance in the Elsevier hospital scoring model.

CONCLUSION

There is no evidence found to support the research hypothesis at this point in time. This outcome maybe the result of a multiplicity of factors to include the (limited) use of the methodologies used in this study, the fact that no fully digitalized hospital (EMRAM stage 7) is yet present in the NL, and/or the organizational competency of the NL hospitals in fully leveraging the EMR to facilitate patient care. Further research is needed to explore these findings.

Custo direto da condução e documentação do processo de enfermagem

RESUMO Objetivo: identificar o custo direto médio (CDM) das atividades realizadas por profissionais de enfermagem visando à condução e documentação do Processo de Enfermagem na Unidade de Clínica Médica de um hospital universitário. Método: foram observadas 1040 atividades e calculado o CDM multiplicando-se o tempo despendido pelos profissionais pelo custo unitário da mão de obra direta. Resultados: o CDM da admissão do paciente correspondeu a R$ 55,57 (DP ±19,44); dentre as atividades de seguimento dos pacientes a documentação do Histórico de Enfermagem representou o CDM mais impactante (R$ 17,70, DP=14,60); o CDM das anotações descritivas correspondeu a R$ 1,21 (DP=1,21) e o CDM da equipe de enfermagem para passagem de plantão foi de R$ 54,23 (DP=28,95). Conclusão: o estudo contribui para conferir visibilidade à atuação dos profissionais de enfermagem na condução do Processo de Enfermagem fornecendo elementos financeiros para argumentação consistente quanto aos recursos adequados à sua exequibilidade.

Effects of health information technology on malpractice insurance premiums

OBJECTIVES

The widespread adoption of health information technology (IT) will help contain health care costs by decreasing inefficiencies in healthcare delivery. Theoretically, health IT could lower hospitals' malpractice insurance premiums (MIPs) and improve the quality of care by reducing the number and size of malpractice. This study examines the relationship between health IT investment and MIP using California hospital data from 2006 to 2007.

METHODS

To examine the effect of hospital IT on malpractice insurance expense, a generalized estimating equation (GEE) was employed.

RESULTS

It was found that health IT investment was not negatively associated with MIP. Health IT was reported to reduce medical error and improve efficiency. Thus, it may reduce malpractice claims from patients, which will reduce malpractice insurance expenses for hospitals. However, health IT adoption could lead to increases in MIPs. For example, we expect increases in MIPs of about 1.2% and 1.5%, respectively, when health IT and labor increase by 10%.

CONCLUSIONS

This study examined the effect of health IT investment on MIPs controlling other hospital and market, and volume characteristics. Against our expectation, we found that health IT investment was not negatively associated with MIP. There may be some possible reasons that the real effect of health IT on MIPs was not observed; barriers including communication problems among health ITs, shorter sample period, lower IT investment, and lack of a quality of care measure as a moderating variable.

A systematic review of the cost of data collection for performance monitoring in hospitals

BACKGROUND

Key performance indicators (KPIs) are used to identify where organisational performance is meeting desired standards and where performance requires improvement. Valid and reliable KPIs depend on the availability of high-quality data, specifically the relevant minimum data set ((MDS) the core data identified as the minimum required to measure performance for a KPI) elements. However, the feasibility of collecting the relevant MDS elements is always a limitation of performance monitoring using KPIs. Preferably, data should be integrated into service delivery, and, where additional data are required that are not currently collected as part of routine service delivery, there should be an economic evaluation to determine the cost of data collection. The aim of this systematic review was to synthesise the evidence base concerning the costs of data collection in hospitals for performance monitoring using KPI, and to identify hospital data collection systems that have proven to be cost minimising.

METHODS

We searched MEDLINE (1946 to May week 4 2014), Embase (1974 to May week 2 2014), and CINAHL (1937 to date). The database searches were supplemented by searching for grey literature through the OpenGrey database. Data was extracted, tabulated, and summarised as part of a narrative synthesis.

RESULTS

The searches yielded a total of 1,135 publications. After assessing each identified study against specific inclusion exclusion criteria only eight studies were deemed as relevant for this review. The studies attempt to evaluate different types of data collection interventions including the installation of information communication technology (ICT), improvements to current ICT systems, and how different analysis techniques may be used to monitor performance. The evaluation methods used to measure the costs and benefits of data collection interventions are inconsistent across the identified literature. Overall, the results weakly indicate that collection of hospital data and improvements in data recording can be cost-saving.

CONCLUSIONS

Given the limitations of this systematic review, it is difficult to conclude whether improvements in data collection systems can save money, increase quality of care, and assist performance monitoring of hospitals. With that said, the results are positive and suggest that data collection improvements may lead to cost savings and aid quality of care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014007450 .

Computerization and its contribution to care quality improvement: the nurses' perspective

BACKGROUND

Despite the widely held belief that the computerization of hospital medical systems contributes to improved patient care management, especially in the context of ordering medications and record keeping, extensive study of the attitudes of medical staff to computerization has found them to be negative. The views of nursing staff have been barely studied and so are unclear. The study reported here investigated the association between nurses' current computer use and skills, the extent of their involvement in quality control and improvement activities on the ward and their perception of the contribution of computerization to improving nursing care. The study was made in the context of a Joint Commission International Accreditation (JCIA) in a large tertiary medical center in Israel. The perception of the role of leadership commitment in the success of a quality initiative was also tested for.

METHODS

Two convenience samples were drawn from 33 clinical wards and units of the medical center. They were questioned at two time points, one before the JCIA and a second after JCIA completion. Of all nurses (N=489), 89 were paired to allow analysis of the study data in a before-and-after design. Thus, this study built three data sets: a pre-JCIA set, a post-JCIA set and a paired sample who completed the questionnaire both before and after JCIA. Data were collected by structured self-administered anonymous questionnaire.

RESULTS

After the JCIA the participants ranked the role of leadership in quality improvement, the extent of their own quality control activity, and the contribution of computers to quality improvement higher than before the JCIA. Significant Pearson correlations were found showing that the higher the rating given to quality improvement leadership the more nurses reported quality improvement activities undertaken by them and the higher nurses rated the impact of computerization on the quality of care. In a regression analysis quality improvement leadership and computer use/skills accounted for 30% of the variance in the perceived contribution of computerization to quality improvement.

CONCLUSIONS

(a) The present study is the first to show a relationship between organizational leadership and computer use by nurses for the purpose of improving clinical care. (b) The nurses' appreciation of the contribution computerization can make to data management and to clinical care quality improvement were both increased by the JCI accreditation process.